Norovirus in a 40-bed care home with two staff off sick and an agency worker arriving
A 40-bed residential care home for older people has had 12 residents and 4 of 22 staff develop vomiting and watery diarrhoea within 48 hours. Three residents share one four-bed room; one of them, Mr Ip, 86, has had two episodes of loose stool and is now drowsy with a dry mouth and reduced skin turgor. Another resident, Mrs Ng, takes warfarin and has eaten little for two days. Two care assistants are off sick and an agency worker who has never worked in the home arrives for the night shift. The home's infection control policy is in a folder in the office; alcohol hand rub is available but the only clinical hand-wash sink is at the far end of the corridor. The manager asks you, the only registered nurse on duty, whether the home should be closed to visitors and whether to send the agency worker home.
1. Set out the outbreak control measures the nurse should initiate tonight, and explain the rationale for each.
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Treat this as a suspected viral gastroenteritis outbreak until proven otherwise. The combination of vomiting, watery diarrhoea, high attack rate among residents and staff, and a closed setting points to norovirus.
- Hand hygiene with soap and water after contact with residents, their environment, vomit or stool; alcohol rub is not reliable against norovirus. Ensure the sink is stocked and that this is demonstrated to every worker tonight.
- Isolate and cohort: keep symptomatic residents in their own rooms with the door closed, or cohort them together; stop communal dining and group activities; serve meals in rooms.
- PPE: gloves and apron for contact, and a fluid-resistant surgical mask and eye protection where splashing or vomiting is likely.
- Dedicated equipment for affected residents; clean and disinfect shared surfaces with chlorine 1000 ppm, especially toilets, door handles, call bells and commodes. Vomit and stool must be cleared and the area disinfected.
- Staff exclusion: symptomatic staff stay off work until 48 hours after symptoms resolve; this applies to the agency worker only if symptomatic. If symptom-free, the agency worker should be orientated, given written instructions and supervised, not sent home - but not deployed to unaffected residents without understanding hand hygiene.
- Visitors: restrict non-essential visiting until the outbreak is controlled; the manager should decide with the outbreak team, not the nurse alone.
- Notify and sample: inform the manager and the local public health unit or Centre for Health Protection, and collect stool specimens as advised so the organism is confirmed.
- Start a line list of residents and staff with dates of onset and symptoms.
2. With two care assistants off sick, how should the nurse prioritise Mr Ip and Mrs Ng, and what can be delegated to the agency worker?
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Prioritise by risk, not by convenience.
Mr Ip: drowsiness, dry mouth, reduced skin turgor and two loose stools suggest dehydration, and drowsiness in an 86-year-old may also be sepsis or a drug effect. Assess level of consciousness, BP, pulse, temperature, capillary refill, urine output and glucose; start an oral rehydration fluid if he can swallow safely, in small frequent amounts, and record intake and output. If he cannot drink, is hypotensive or becomes more drowsy, escalate to the GP or ambulance service for intravenous fluids. Consider whether an infection-control move to a side room is possible.
Mrs Ng: poor intake for two days plus dehydration increases the effect of warfarin while reduced vitamin K intake pushes the INR up. Check for bleeding, bruising and falls, ensure she is drinking, and arrange a GP review and INR check rather than altering warfarin yourself.
Delegation to the agency worker: people can be delegated feeding, toileting, repositioning, measuring and recording intake, output and temperature, and cleaning with chlorine solution - after orientation, written instructions and confirmation of understanding. The registered nurse keeps the assessment, the clinical judgements, medication administration, decisions about escalation and the outbreak documentation, and remains accountable for everything delegated. Do not delegate Mr Ip's first assessment.
3. What should the nurse record and communicate about this outbreak, and how should the outbreak be reviewed afterwards?
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Record contemporaneously, because evidence of an outbreak is also evidence of the response.
- A line list for residents and staff: name, room, date and time of first symptom, type of symptom, specimens taken, isolation status and outcome.
- Instructions given to staff, including the agency worker, and who confirmed they understood.
- Times of notification to the manager and the public health unit, with the name of the person contacted.
- Cleaning schedules and products used.
- Care and escalation for Mr Ip and Mrs Ng, including each set of observations, intake and output, and the advice received.
- The decision about visitors, who made it, and how families were informed.
Communicate in plain language: tell families why visits are restricted, and give a single contact number; ensure domestic and catering staff know what to do; hand over the line list at each shift change.
Review afterwards: calculate attack rates, check whether specimens confirmed norovirus, identify what delayed the response - for example, only one clinical hand-wash sink and an unwieldy paper policy - and put those into an action plan with the manager. Complete an incident report and consider whether staff availability and cleaning resources need to be written into the home's outbreak plan.